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Choosing to Breastfeed


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I was contracted by Health Canada to develop and lead a workshop on communicating with mothers about breastfeeding. The workshop was part of a day-long series of workshops hosted by Health Canada for members of its staff.

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Choosing to Breastfeed

  1. 1. Choosing to Breastfeed Ann Douglas, Author; President, Mom Media
  2. 2. Overview I. What Mothers Need to Know About Breastfeeding II. Mothers' Top Worries and Concerns About Breastfeeding III. Helping Mothers to Deal With Common Breastfeeding Problems IV. Breastfeeding Promotion: What Works and What Doesn't Work—Summarizing the Results from Some Key Studies V. Communicating Effectively with Mothers About Breastfeeding VI. Recommended Resources
  3. 3. I. What Mothers Need to Know About Breastfeeding • Breastfeeding offers tremendous health benefits to mothers and babies. Two years and beyond. • The quantity and the specific composition of breast milk changes in order to meet baby's need at any given time.
  4. 4. • A baby may breastfeed more frequently in hot weather or during a growth spurt. Growth spurts typically occur at around two to three weeks, six weeks, three months, and six months of age. • Breastfeeding doesn't come naturally or easily to every mother and baby. There can be a learning curve for one or both; and the problems to be overcome during the early weeks can range from the easy-to- troubleshoot to the much more challenging to resolve. Breastfeeding is worth it
  5. 5. • The pressure to breastfeed can be considerable— something that can be either motivating or overwhelming, depending on both the amount of pressure and the individual mother's reaction to the pressure that is being exerted. “I feel really strongly that new moms should not be pressured into breastfeeding or made to feel guilty if they choose not to breastfeed or it simply doesn’t work out. I get very angry at those who say that at all costs every mother can breastfeed. It’s like saying that every woman with a working uterus can be a good mother! This is not the case. I have friends who tried very hard to breastfeed, and even with extra pumping and fees, their breasts simply would not produce enough milk. That doesn’t make them ‘bad mothers.’” - Judith, 31, mother of oneQuotes from mothers are excerpted from The Mother of All Baby Books By Ann Douglas (Wiley Canada, 2001).
  6. 6. Breastfeeding is much more than a form of nutrition. It is a special way to bond with your child: to learn how to be a mother.” - Elisa, 27, mother of two • Once you reach "the reward period" of breastfeeding, breastfeeding can be a wonderful way to snuggle up to baby, a source of feel-good mothering hormones, and a powerful mothering tool.
  7. 7. • Breastfeeding may be the healthiest and most natural way of feeding a baby, but breastfeeding isn't necessarily the right choice for every mother and baby.
  8. 8. • Learning about breastfeeding before your baby is born, setting a breastfeeding goal for yourself, and connecting with sources of breastfeeding support and information after the birth can increase your odds of being able to breastfeed over the long-term. “Enter into breastfeeding with an open mind. You may feel now that you only want to breastfeed for six weeks or so, but you may be shocked by your pull to keep going.” - Jennifer, 26, pregnant with her second child
  9. 9. • Babies may not be able to talk, but they have ways of communicating their desire to breastfeed: rooting, clicking their tongues, and sucking on their fingers or their hands. “Breastfeeding is the most natural way of nourishing your baby and it makes mothering easier.” - Jennifer, 26, pregnant with her second child • They can also tell you when they've had enough to eat: they may stop nursing and turn their head away, relax in your arms, and stretch out their arms and legs and their fingers.
  10. 10. • The milk tide ebbs and flows. Your milk supply is more abundant in the morning than it is at night. That said, you can be caught off guard by leaks, squirts, and spurts. Breast pads and a sense of humor are a breastfeeding mother's best friends. • There also peaks and valleys in your energy cycle. These are tied to your sleep-wake cycle, the last time you ate, and your baby's sleep- wake-feeding cycle. • Life is easier as a breastfeeding mom if you learn to "go with the flow."
  11. 11. II. Mothers' Top Worries and Concerns About Breastfeeding "I can't tell how much milk my baby is getting." Swallowing signs, breastfeeding at least 8 times/day, having 3 to 4 bowel movements every 24 hours after Day 4 (although some babies may go a week or longer without a bowel movement starting at around Week 6), gaining weight (after the initial post-birth weight loss of 5 to 8% of birth weight, which is normal).
  12. 12. "My milk hasn't come in yet. I'm worried he's starving to death.” Ideally baby should regain his birth weight by age two weeks and to continue to gain four to eight ounces (120 to 240 grams) per week during the first three months of life. Newborns only need tiny quantities of colostrum (the nutrient-rich first food). Transitional milk comes in (around day 4): about 2 ounces of milk per feeding. Up to about 2 to 2 ½ ounces of breast milk by the time your actual breast milk comes in the following day (around day 5).
  13. 13. Breast Milk - Best Milk (2003) Colostrum, foremilk, and hindmilk A breastfeeding poster published by Britain’s National Childbirth Trust
  14. 14. "Is breast milk supposed to look like that?" Breast milk is supposed to look like a whitish-bluish version of the most watered down skim milk you've ever seen. That's normal.
  15. 15. "How often should my newborn be nursing?” Resist the temptation to schedule feedings, to time feedings, or to limit time at the breast. Your baby will let you know when he's hungry and when he's had enough to eat. Up to 6 weeks of age: Up to 12 times/day. 6 weeks of age: Up to 10 times/day. 3 months: approximately 8 times/day. You'll probably notice that your baby "cluster feeds" (has a couple of feedings that are closely spaced together). This is normal.
  16. 16. "What foods should I eliminate from my diet in order to reduce my baby's fussiness?" Foods that have been blamed for making babies edgy, cranky, or colicky include caffeine, dairy products, eggs, gluten, corn, fish, nuts, soy, gassy vegetables, spicy foods. Try to figure out what food might have triggered your baby's fussiness and then try to eliminate that food or food group for two weeks. Then gradually re- introduce the food and see if you notice a difference in your baby's symptoms.
  17. 17. "What's the earliest I should introduce a bottle or a pacifier?" Opinions vary. It's easier to get milk out of a bottle than a breast. Time spent sucking on an artificial nipple is time that isn't spent at the breast stimulating milk production. On the other hand, if mom is feeling like she's turned into a human pacifier 24/7, and nursing is well established, it may be worthwhile weighing the pros/cons of pacifier use.
  18. 18. "Is it okay to offer a breastfed baby the occasional bottle of formula?" Exclusive breastfeeding is the preferred option because infant formula is very different from breast milk.
  19. 19. "Is it okay to drink alcohol while you're nursing?" Most health authorities advise limiting yourself to one alcoholic beverage per day and timing that drink so that you have it right after a feeding. Alcohol can make breastfeeding babies extra drowsy, which can interfere with breastfeeding.
  20. 20. "I've heard that smoking affects breastfeeding, too." Smoking decreases milk production, interferes with milk ejection, lowers prolactin levels and fat levels in milk, and increases the incidence of infant colic. What's more, exposure to second-hand smoke increases a baby's risk for Sudden Infant Death Syndrome, respiratory infections, and cancer.
  21. 21. Nutrition for Healthy Term Infants states that breastfeeding mothers should be encouraged to stop or reduce smoking, but adds, "Even if smoking is continued, breastfeeding is still the best choice." (Revision: 12/08/05).
  22. 22. La Leche League International offers this sensible advice: • Smoke away from the baby, outdoors, or in a separate room. • Smoke right after nursing sessions. • Smoke as few cigarettes as possible.
  23. 23. "Is it safe to take this medication or herbal product?" Medications and herbal products pass through breast milk to babies. Some products are known to be harmful to babies. Contact the Motherisk Clinic; 1-877-327-4636.
  24. 24. "Which position should I use?” See So That's What They're For by Janet Tamaro for mom-friendly explanations of these particular breastfeeding positions or download this document from the La Leche League website: positioning.html The position that works for you and your baby—and there are a smorgasbord of choices to choose from: the cradle position, the transition position, the clutch or football position, the cradle lying down position, the alternate lying down position, the cross- cradle position, etc.
  25. 25. “Because I’m big-breasted, the regular football or cradle hold just wouldn’t work for me. I placed a rolled-up face cloth under by breast to raise it up and give me more support.” - Tammy, 32, mother of one
  26. 26. "When should I start my breastfed baby on solid foods?” You don't need to give babies anything other than Vitamin D drops during that time. Water, juice, sugar water, and formula are not necessary for breastfed babies. Encourage exclusive breastfeeding for the first 6 months of life, as breast milk is the best food for optimal growth. Breastfeeding may continue for up to 2 years and beyond. - Nutrition for Healthy Term Infants (Ottawa: The Canadian Paediatric Society Nutrition Committee, Dietitians of Canada and Health Canada, Rev. 2005)
  27. 27. "Is it okay to diet when I'm breastfeeding?” While some women lose weight while they're breastfeeding, dieting is not recommended. Talk to your healthcare provider if you are concerned about your weight. Healthy nutrition is important for breastfeeding mothers. Structure your meals and snacks around Canada's Food Guide. You will probably find that you want to have a snack and a drink handy while you're feeding your baby.
  28. 28. III. Helping Mothers to Deal With Common Breastfeeding Problems Baby is too sleepy to nurse Following a period of initial alertness, most newborns become quite sleepy. Babies with jaundice are extra sleepy. Attempt to rouse baby during periods of active sleep (when baby's eyes are moving and he's "nursing" in his sleep). Do "baby sit- ups" while supporting baby's head. Undress baby, but don't allow baby to become chilled. This table is modified from a more detailed chart which can be found on pages 22 t o 33 of Mealtime Solutions for Your Baby, Toddler, and Preschooler: The Ultimate No-Worry Guide for Each Age and Stage by Ann Douglas (John Wiley and Sons Canada Ltd: Toronto, 2006). All material © Ann Douglas and John Wiley and Sons Canada Ltd.
  29. 29. Baby doesn't want to nurse If a newborn refuses the breast, it's called "breast refusal"; when an older baby refuses the breast, it's called a "nursing strike." Figure out what's at the root of the problem. Is baby frustrated with breastfeeding? in pain? (sore mouth, sore teeth, sore throat, ear infection) picking up on stress in the family? Soothe and reassure your baby and offer the breast when baby is sleepy. Offer pumped breast milk via alternative means, ideally avoiding a bottle.
  30. 30. Breast engorgement Your baby can't extract milk from your overly firm breasts; and baby's poor latch leaves you susceptible to sore nipples. Apply warm compresses right before feedings to encourage milk flow and apply cold compresses (frozen peas) in between feedings to reduce swelling. Nurse frequently (at least 8 to 12 times/day) and watch for signs of a breast infection (fever, redness, breast soreness).
  31. 31. Inadequate milk supply Most women produce enough milk for their babies. In general, if your baby is producing one wet diaper on Day 1, two wet diapers on Day 2, and so on until Day 5 (at which point you want to see five to six wet diapers per day and a couple of yellowish stools), you should feel reassured. If you are still worried, have your healthcare provider check your baby's weight, latch, and overall health. To build up your milk supply • check baby's latch • ensure baby nurses actively for at least 10 minutes at each breast • breastfeed at least 8 times per day • offer each breast at each feeding and express milk (or pump) after each feeding to further stimulate milk production • ask if a prescription or herbal product would help
  32. 32. Overabundant milk supply Your baby chokes, gulps, or pulls away from the breast because he can't manage the flow of milk. Some babies simply refuse to nurse. Offer one breast per feeding. Pump or hand- express some milk before you offer the breast to your baby so that the milk flow won't be quite so overpowering. Nurse in the side- lying position so that baby can let any extra milk dribble out of his mouth.
  33. 33. Flat or inverted nipples It is more difficult for a baby to latch on to flat or inverted nipples and the nipple is more susceptible to injury. Use a breast pump immediately prior to each nursing session. This will encourage the nipple to protrude long enough for baby to get a good latch. Positioning problems Baby is latching on to the nipple itself rather than the areola (shallow latch). This leads to sore nipples, poor letdown, poor milk flow, and reduced milk production. Check baby's position.
  34. 34. Nipple trauma Overuse or improper use of a breast pump; pulling the baby off the breast without breaking the suction with your baby finger. If your breast pump is causing you pain or discomfort, stop pumping. Break the suction in your baby's mouth before you remove your baby from the breast.
  35. 35. Breast infection Your nipples can become cracked and infected with bacteria or yeast. You will require treatment with oral antibiotics (for a bacterial breast infection) or anti- fungal medication (for a yeast-based breast infection).
  36. 36. Mastitis If a plugged milk duct becomes infected, you can develop a fever that is accompanied by symptoms of a breast infection (red streaks on your breast, a cracked nipple that oozes pus, and pus or blood in your milk). • Keep nursing to avoid engorgement. • Apply warm water (shower, bath, basin) and massage your breasts in a circular motion (armpit to nipple) before nursing to encourage milk flow. Cabbage leaf compresses work well, too. • If baby refuses to nurse on the affected side, pump from that side and continue to offer the other breast.
  37. 37. “With my two boys, I developed mastitis. My body started aching, and there was this hard lump in my breast. I started running a fever and having chills and generally feeling the most ill I’d ever felt in my life. If you develop mastitits, it really helps to breastfeed often, especially on the infected side. You should also make sure you keep your breasts dry and that you change your breast pads often. Try massaging the hard lump in a warm bath and applying warm compresses and see if that helps, and call your doctor to see if an antibiotic is in order.” - Christina, 25, mother of two
  38. 38. • Avoid tight clothing, particularly tight bras. • Take a pain medication as needed. • Get plenty of rest.
  39. 39. Thrust/yeast infections You may notice white patches inside your baby's mouth, a white tongue (thrust), or a fiery-red yeast- based diaper rash. Your baby may seem like he's in pain when he's nursing. You may feel sharp, burning pains in your nipple. The skin of the areola may or may not be affected. (If it is, it may be itchy and scaly or red and shiny). Seek treatment for yourself, your baby, and your partner. (Yeast infections can be transmitted during sex.) Treatment options include nystatin cream or ointment, gentian violet, or anti-fungal creams.
  40. 40. Baby with reflux Gastroesophageal reflux disease (GERD) occurs when stomach acids back up into the esophagus, causing extreme distress during and after feedings and when baby is lying down after a feeding. Positions that keep your baby's head elevated during a feeding work best for babies with GERD. Keep baby upright for at least half an hour after each feeding. Talk to your healthcare provider about the advisability of modified sleeping positions for babies with GERD.
  41. 41. Babies with special feeding issues Babies who are premature may not be capable of feeding at the breast or staying awake for a full feeding at the breast initially. Babies who are tongue- tied (frenulum is unusually short), or who have a physical condition or structural problem that makes breastfeeding more difficult (e.g., Down syndrome, cleft lip, or cleft palate) may require modified breastfeeding holds or surgery in order to breastfeed. Consult with a lactation consultant to find out how to make breastfeeding and breast pumping work for your baby. There are special feeding devices that can be helpful to babies with cleft palate; for example, a palatal obturator: a mouth appliance that provides a firm surface at the roof of the mouth; and a Haberman feeder (a bottle that can be adjusted for slower or faster flow and that is compression rather than sucking driven).
  42. 42. Breastfeeding Tricks of the Trade: Practical Strategies to Share with Mothers • Stay as calm and relaxed as possible, even if you're having a tough time. If you become stressed, baby will pick up your stress signals and become stressed, too. That will make breastfeeding more challenging for both of you. • Read your baby's feeding cues so that you can offer the breast at a time when baby is most likely to be responsive. • Help your baby to achieve a good latch. Aim for what Mohrbacher and Kendall-Tackett describe as "the comfort zone"—a deep latch that is comfortable for mom and that provides a steady milk flow for baby.
  43. 43. Watch for these common positioning problems • Baby's body is twisted. • Baby's feet are pushing against the arm of a chair or other surface, so baby is able to push herself off the breast. • Baby's chin is pressed down against her chest, which makes swallowing difficult and which tends to press her nose into the breast, which makes breathing more difficult for baby.
  44. 44. IV. Breastfeeding promotion: What works and what doesn't work—summarizing the results from some key studies Sciacca, JP, DA Dube, BL Phipps, MI Ratliff. "A breastfeeding education and promotion program: effects on knowledge, attitudes, and support for breastfeeding." J Community Health. 1995: Dec;20(6):473-90. Prizes can work really well in promoting breastfeeding. Special incentives (prizes) were offered to women and their partners for participating in several breastfeeding education and promotion activities. Special incentives (prizes) for women and their partners to participate in several breastfeeding education and promotion activities. Researchers concluded that offering prizes can produce positive changes in breastfeeding knowledge, attitudes, and support, and can have a dramatic effect in promoting breastfeeding.
  45. 45. Guise, Jeanne-Marie, MD, MPH; Valerie Palda, MD, MPH; Carolyn Westhoff, MD, MSc; Benjamin K. S. Chan, MS; Mark Helfand, MD, MS; and Tracy A. Lieu, MD, MPH. "The Effectiveness of Primary Care-Based Interventions to Promote Breastfeeding: Systematic Evidence Review and Meta-Analysis for the US Preventive Services Task Force." Annals of Family Medicine 1:70-78 (2003). Telephone support is more effective than written materials like pamphlets: Support programs conducted by telephone, in person, or both increased short-term and long-term duration. In contrast, written materials such as pamphlets did not significantly increase breastfeeding.
  46. 46. "The effect of peer support on breast-feeding duration among primiparous women: a randomized controlled trial.” Dennis, Cindy-Lee, Ellen Hodnett, Ruth Gallop and Beverley Chalmers.CMAJ, January 8, 2002; 166 (1). Mother-to-mother telephone support is extremely effective and mothers love it: The telephone-based peer support intervention was effective in maintaining breast-feeding to 3 months post partum and improving satisfaction with the infant feeding experience. Of 130 mothers, 81.6% were satisfied with their peer volunteer experience and 100% felt that all new breast-feeding mothers should be offered this peer support intervention.
  47. 47. "The Impact of a New Universal Postpartum Program on Breastfeeding Outcomes." Debbie Sheehan, RN, MSW; Susan Watt, DSW, RSW; Paul Krueger, PhD; Wendy Sword, RN, PhD. Journal of Human Lactation, Vol. 22, No. 4, 398- 408 (2006). Postpartum visits and phone calls from a public health worker don't affect a mother's decision to breastfeed longer: Extended length of stay, a postpartum phone call from a public health worker, or a postpartum in-home visit did not affect a mother's decision to continue breastfeeding until 4 weeks. Maternal attitudes toward breastfeeding, formula feeding or supplementation in hospital, infant readmission, and use of walk-in clinics for infant care were associated with breastfeeding discontinuation before four weeks post-discharge.
  48. 48. Canada Prenatal Nutrition Program Guiding Principles • Mothers and Babies First The health and well-being of the mother and baby are most important in planning, developing and carrying out every project. • Strengthening and Supporting Families Families have the main responsibility for the care and development of their children. However all parts of Canadian Society, governments, agencies, employers, organized labour, educators and voluntary community organizations share the responsibility for children by supporting parents and families. • Equity and Accessibility Projects must meet the social, cultural and language needs of pregnant women in the community and must be available in all parts of the country, particularly isolated areas or those with poor access to services, to women with disabilities, to Aboriginal women, and to recent immigrants and refugees. • Partnerships Partnerships and cooperative activities at the community level are the key to developing effective programs. Projects must work in partnership with other services in the community.
  49. 49. • Community based Decision making and action must be community based. Pregnant women, new mothers, families and community groups must have an active role in planning, designing, operating and evaluating projects. New projects and changes to existing projects must be based on what participants need and want, and be appropriate to the culture and language of the women. • Flexibility Projects must be flexible to respond to the different needs in each community and to the changing needs and conditions of women in these communities. Source: Canada Prenatal Nutrition Program: A Practical Workbook to Protect,Promote and Support Breastfeeding in Community Based Projects. Minister of Public Works and Government Services Canada, 2002.
  50. 50. V. Communicating Effectively with Mothers About Breastfeeding When you're talking to mothers about breastfeeding, don't forget your CAMERA.
  51. 51. • Clear: Aim for messages that are clear and concise. Remember that you're dealing with a sleep-deprived mom who may be distracted by her baby and possibly other children, so it doesn't hurt to make your key point(s) a couple of different ways. • Accurate: Stay on top of new developments in your field so that you can provide relevant, accurate, and up-to-date information. This will allow you to dispel breastfeeding myths in a credible manner. • Memorable: Provide new moms with pamphlets, tip sheets, wallet cards, checklists, and other helpful breastfeeding resources that will make it easier for them to remember the information that you conveyed during your visit. Also strive to make the visit memorable in other ways—by establishing a warm and caring connection and, in some cases, giving moms concrete reasons for wanting to remember your messages (incentives such as donated prizes and giveaways: see Journal of Community Health, 1995 Dec; 20(6):473-90).
  52. 52. • Empathetic: Be empathetic and non-judgmental. Breastfeeding is a very emotional issue for mothers. Moms who are experiencing breastfeeding difficulties often struggle with feelings of guilt and self-doubt. A negative breastfeeding experience can stay with a mother for a very long time. • Reassuring: Mothers need to hear what a great job they are doing. They also need to be reassured that it's normal to feel like they've been transported to another planet (Planet Mom!) and that they still haven't regained their bearings quite yet. Being truly heard by someone who cares and who reassures her that her feelings are normal can make a huge difference in the life of a new mom.
  53. 53. • Accessible: Ensure that the service that you are providing is as accessible as possible: financially accessible, physically accessible, accessible in terms of language and literacy level, accessible in other practical terms (hours of operation, childcare needs, location, etc.) Here's something to ask yourself: Can mothers obtain your services (or do they have access to a similar service) at those times when their need for breastfeeding answers and support is particularly pressing? Do they know where they can call for information and support at 3 am?
  54. 54. VI. Recommended Resources • Canada Prenatal Nutrition Programme (CAPC/ CPNP) resources on Public Health Agency of Canada website. • List of books, videos, and online resources in workshop materials. For further inspiration, consider what others in the field of breastfeeding promotion are doing elsewhere -- in other communities; in other parts of the world.
  55. 55. New Zealand Aboriginal breastfeeding campaign poster from New Zealand.
  56. 56. Mothers’ Milk Marketing Board, UK
  57. 57. Posters from Sri Lanka and France; Statue from Brazil
  58. 58. Health Canada and INFACT Canada
  59. 59. Ted Greiner’s Breastfeeding Website